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If Medicare or your Medicare plan denies coverage or payment for healthcare services, items, or drugs you believe you should receive, you have the right to appeal. This guide explains the appeals process for all Medicare plans, helping you navigate the steps to challenge a denial.
Understanding Medicare Appeals
An appeal is the action you take when you disagree with a coverage or payment decision made by Medicare or your Medicare plan. You have the right to appeal if Medicare or your plan:
- Denies a request for healthcare service, supply, item, or prescription drug you think you should get
- Refuses payment for healthcare you already received
- Wants to change the amount you must pay
- Stops providing or paying for all or part of a service you think you still need
The appeals process involves multiple levels. If you disagree with a decision at one level, you can proceed to the next. Each level has specific rules, deadlines, and procedures.
Appeals differ from grievances, which are complaints about quality of care or services not related to coverage decisions.
Who Can File an Appeal?
Several parties can file Medicare appeals:
- You (The Beneficiary): You always have the right to file an appeal yourself.
- Your Representative: You can appoint someone to act on your behalf by submitting a completed “Appointment of Representative” form (CMS-1696) or a written request with required elements.
- Your Doctor or Prescriber (in certain situations):
- For Medicare Advantage plans: Your treating doctor can request first-level appeals without needing the representative form
- For Medicare Drug Plans: Your doctor can request coverage determinations and first/second-level appeals without the form
What Decisions Can Be Appealed?
Original Medicare (Part A & B)
You can appeal decisions on your Medicare Summary Notice (MSN) if you disagree with:
- Denial of payment for services you received
- Refusal to cover a service you believe should be covered
- The amount Medicare paid
- Termination of services like hospital care, skilled nursing, home health, or hospice
- Denial of Part A coverage for a hospital stay reclassified as outpatient observation
Before appealing, contact your provider to ensure the denial wasn’t just a billing error.
Medicare Advantage (Part C) Plans
You can appeal if your plan:
- Refuses to provide or pay for services you believe should be covered
- Reduces or stops a service you think you still need
- Denies payment for care you already received
- Discharges you from a facility or terminates services sooner than appropriate
Medicare Prescription Drug (Part D) Plans
For Part D plans, you first request a “coverage determination” from your plan. If unfavorable, you can appeal if the plan refuses to:
- Cover a prescription drug you believe should be covered
- Grant an exception request (for non-formulary drugs or to waive restrictions)
- Pay for a drug you already purchased
- Change your cost-sharing amount
The 5 Levels of Appeal in Original Medicare
Level 1: Redetermination by the Medicare Administrative Contractor (MAC)
What it is: A review by personnel not involved in the initial decision.
How to File:
- Submit a written request using the Medicare Redetermination Request Form or write a letter with your information and why you disagree
- Include supporting documents from your doctor
- Send to the MAC address listed on your Medicare Summary Notice
Deadline: 120 days from receiving the initial determination
Timeline: The MAC usually decides within 60 days
Level 2: Reconsideration by the Qualified Independent Contractor (QIC)
What it is: An independent review by a company separate from Medicare.
How to File:
- Submit a written request using the Medicare Reconsideration Request Form or write a letter
- Important: Include ALL evidence you want considered. Evidence not submitted at this level might be excluded from later reviews
Deadline: 180 days from receiving the MAC’s decision
Timeline: The QIC generally decides within 60 days
Level 3: Hearing by an Administrative Law Judge (ALJ)
What it is: A hearing before an Administrative Law Judge at the Office of Medicare Hearings and Appeals (OMHA).
Key Requirements:
- The amount in dispute must meet a minimum threshold ($190 for 2025)
- Hearings are usually by phone or video, though in-person hearings may be granted
- You can request a decision based on written record without a hearing
How to File:
- Use Form OMHA-100 or submit a written request
- File by mail or through the OMHA e-Appeal Portal
Deadline: 60 days from receiving the QIC’s decision
Timeline: OMHA should decide within 90 days, but delays are common
Level 4: Review by the Medicare Appeals Council
What it is: A review by the Medicare Appeals Council (part of the Departmental Appeals Board).
How to File:
- Use Form DAB-101 or submit a written request
- Include a copy of the ALJ’s decision
Deadline: 60 days from receiving the ALJ’s decision
Timeline: The Council aims to decide within 90 days
Level 5: Judicial Review in Federal District Court
What it is: Filing a lawsuit in a U.S. District Court.
Key Requirements:
- The amount in dispute must meet a minimum threshold ($1,900 for 2025)
- You’ll likely need legal assistance
Deadline: 60 days from receiving the Appeals Council’s decision
Summary Table: Original Medicare Appeals
| Level | Name | Reviewing Entity | Filing Deadline | Decision Timeline | AIC Required (2025)? | Key Forms/Notes |
|---|---|---|---|---|---|---|
| 1 | Redetermination | Medicare Admin. Contractor (MAC) | 120 days | 60 days | No | CMS-20027 or written request |
| 2 | Reconsideration | Qualified Independent Contractor (QIC) | 180 days | 60 days | No | CMS-20033. Submit ALL evidence |
| 3 | ALJ Hearing | OMHA / Admin. Law Judge | 60 days | 90 days (often delayed) | Yes ($190) | OMHA-100. Notify other parties |
| 4 | Appeals Council Review | Medicare Appeals Council | 60 days | 90 days | No | DAB-101. Notify other parties |
| 5 | Judicial Review | Federal District Court | 60 days | Varies | Yes ($1,900) | File civil lawsuit |
Appealing Decisions in Medicare Advantage (Part C) Plans
Level 1: Reconsideration by Your Plan
What it is: Your first step is asking the plan itself to reconsider its denial.
How to File:
- Follow directions in the plan’s denial notice
- Standard requests generally must be in writing
- Expedited requests can be verbal or written
Who Can File: You, your representative, or your doctor (without needing a formal appointment form)
Deadline: 65 calendar days from the denial date
Timeline:
- Standard Pre-service Appeal: 30 days
- Standard Payment Appeal: 60 days
- Part B Drugs Appeal: 7 days
- Fast (Expedited) Appeal: 72 hours
If denied, your case is automatically forwarded to Level 2.
Level 2: Review by the Independent Review Entity (IRE)
What it is: An independent, outside organization contracted by Medicare reviews the plan’s decision.
How it Starts: Your plan automatically sends the case to the IRE if it denies your Level 1 reconsideration.
Submitting More Information: You can submit additional evidence to the IRE within 10 calendar days after receiving notice that the IRE has your case.
Timeline:
- Standard Pre-service Appeal: 30 days
- Standard Payment Appeal: 60 days
- Standard Part B Drugs Appeal: 7 days
- Fast (Expedited) Appeal: 72 hours
Levels 3-5 for Medicare Advantage
Levels 3, 4, and 5 follow the same path as Original Medicare appeals (ALJ Hearing, Appeals Council Review, Federal District Court).
Summary Table: Medicare Advantage (Part C) Appeals
| Level | Name | Reviewing Entity | Filing Deadline | Decision Timeline (Std/Fast) | AIC Required? | Key Forms/Notes |
|---|---|---|---|---|---|---|
| 1 | Reconsideration | Your Medicare Advantage Plan | 65 days | 30-60 days / 72 hours | No | Plan auto-forwards if denied |
| 2 | IRE Review | Independent Review Entity | Auto-forwarded | 30-60 days / 72 hours | No | Submit extra evidence within 10 days |
| 3 | ALJ Hearing | OMHA / Admin. Law Judge | 60 days | 90 days (often delayed) | Yes | Similar to Original Medicare |
| 4 | Appeals Council | Medicare Appeals Council | 60 days | 90 days | No | Similar to Original Medicare |
| 5 | Judicial Review | Federal District Court | 60 days | Varies | Yes | Similar to Original Medicare |
Appealing Decisions in Medicare Drug Plans (Part D)
Before You Appeal: Coverage Determinations & Exceptions
Coverage Determination: Before formally appealing, you must first ask your plan for a “coverage determination” if:
- Your pharmacist says the plan won’t cover a drug
- The plan requires prior authorization or has restrictions you disagree with
- You disagree with your cost-sharing amount
- You need the plan to pay for a drug you already purchased
Exception Requests: If you need a non-formulary drug or want a restriction waived, you request an “exception.” This requires a supporting statement from your doctor explaining medical necessity.
Timeline for Plan’s Decision:
- Standard Request: 72 hours
- Expedited Request: 24 hours
- Payment Request: 14 calendar days
Level 1: Redetermination by Your Plan
How to File:
- Follow the instructions on the denial notice
- Standard requests must generally be in writing
- Use the Model Redetermination Request Form or write a letter
Deadline: 65 calendar days from the coverage determination notice
Timeline:
- Standard Benefits Appeal: 7 calendar days
- Standard Payment Appeal: 14 calendar days
- Fast Appeal: 72 hours
Level 2: Reconsideration by the Independent Review Entity (IRE)
What it is: An independent review by the Part D IRE (C2C Innovative Solutions).
How to File:
- Unlike Medicare Advantage, you must file a request with the IRE
- Use the Request for Reconsideration form or write your own request
- Submit to C2C Innovative Solutions via their portal, mail, or fax
Deadline: 65 calendar days from the plan’s redetermination decision
Timeline:
- Standard Benefit Appeal: 7 calendar days
- Standard Payment Appeal: 14 calendar days
- Fast Appeal: 72 hours
Levels 3-5 for Medicare Part D
Higher levels follow the same process as Original Medicare (ALJ Hearing, Appeals Council, Federal Court).
Fast Appeals (Expedited Reviews)
Medicare provides two main types of fast appeals:
Fast Appeals for Urgent Health Needs
When to Use: When waiting for a standard decision could seriously jeopardize your life, health, or ability to regain maximum function.
How to Request: You or your doctor can request expedited review directly from the reviewing entity.
Decision Timelines:
- MA Plan/IRE: 72 hours
- Part D Coverage Determination: 24 hours
- Part D Redetermination/IRE: 72 hours
Fast Appeals When Services Are Ending
When to Use: When you’re already receiving Medicare-covered care (hospital, SNF, home health, etc.) and believe services are ending too soon.
Provider Notice: Your provider must give you a specific written notice before services end.
Requesting Review: Contact the Beneficiary and Family Centered Care-Quality Improvement Organization (BFCC-QIO) by the deadline on your notice (typically noon of the day before discharge).
Benefit: If you request timely, you can continue receiving services while the BFCC-QIO decides.
Gathering Strong Evidence for Your Appeal
Submit all supporting evidence by Level 2 of the appeals process. Key evidence includes:
- Letter from Your Doctor: Explaining your diagnosis, treatment history, why the denied service is medically necessary, and why alternatives aren’t appropriate
- Relevant Medical Records: Progress notes, test results, therapy notes, etc.
- Medicare Summary Notice/EOB: Showing the denial
- Prior Appeal Decision Letters: Include when filing for next level
- Bills and Itemized Statements: Showing financial impact
Tips for Documentation:
- Keep copies of everything
- Organize documents logically
- Highlight key information
- Include a brief cover letter
- Write your Medicare Number on every page
- Use certified mail or fax with confirmation
Where to Find Free Help
State Health Insurance Assistance Programs (SHIP)
- Free, personalized counseling in every state
- Help with understanding denials and filing appeals
- Find your local SHIP at shiphelp.org or call 1-877-839-2675
Medicare Rights Center
- Free expert counseling and advocacy
- National helpline: 1-800-333-4114
- Website: medicarerights.org
1-800-MEDICARE
- Official Medicare helpline (1-800-633-4227)
- Available 24/7
- Provides forms and general information
Legal Aid Services
- For complex appeals, especially at higher levels
- Local Bar Association or legal aid societies
- LawHelp.org can help find local resources
Tips for Success
- Understand the Denial: Read the notice carefully to address the specific reason
- Check for Billing Errors: Contact your provider first to rule out simple mistakes
- Meet Every Deadline: Missing a deadline can mean losing your right to appeal
- Keep Records: Maintain copies of everything related to your appeal
- Be Clear and Organized: Use official forms when available
- Appoint a Representative if needed
- Don’t Give Up: Many appeals denied at lower levels are overturned later
- Use Free Help Resources: SHIP, Medicare Rights Center, or 1-800-MEDICARE
Our articles make government information more accessible. Please consult a qualified professional for financial, legal, or health advice specific to your circumstances.
